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CITYof ORONO <br /> Post Office Box 660 Crystal Bay,Minnesota N.WoMunidysl Office® <br /> o On the North Shore of Lake Minnetonka <br /> In accordance with M.S. 15.165, "Rights of subjects of data", we <br /> would like to inform you that your request for a permit or license <br /> f rom the City of Orono or any of its departments may require you to <br /> furnish certain private or confidential information. <br /> You are motif ied that s <br /> 1. The information you furnish will be used to determine your <br /> qualification for the permit or license requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit or license. s <br /> 3. The information may be shared with other local, state or <br /> federal agencies to the extent necessary to process the permit or <br /> license. <br /> 4. If your requested permit or license requires Council action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 15.165 to review private <br /> data on yourself. <br /> 6. Your full name, and .date of birth are required to process <br /> this application or permit. <br /> F rst a Last <br /> Address <br /> W D.L V(] Om U4 <br /> 2� <br /> ty state zip <br /> . . . . <br /> . Phone . <br /> I er®tand my rights a stated above. : <br /> . gnature _ <br /> BUUJMG R ZONINO-473.7357 • ADM]N1S4RA?1ON R FINANCE-473.7358 . • PUBUC WORKS-473.73S9 <br /> ASSOUNO <br />